Sample II-10: Family Literacy Program Needs Assessment Interview (All Levels)City:________________________ Site: _________________________________________ Date:________________________ Interviewer: ___________________________________ Information about Parent or Guardian EnrollingInterviewer Introduction: My name is (Interviewer's Name). With your permission I would like to ask you some questions about you, your background, why you are enrolling in a class, and are enrolling (Child's Name) with you. Parent and Child Information: First I need to get some general information about you and (Child's Name), such as your address and telephone number. (Fill in information.) Full Name of Adult:____________________________________________________________ First Name:_________________________ Date of Birth: ____________________________ Address: ____________________________________________________________________ Telephone: ______________ Cell Phone: _________________ E-mail: __________________ Date of Enrollment:_______________ Gender:
1. Adult Learner Background Interviewer Instructions: What is your race or ethnicity? (Check all responses given.) ![]() ![]() ![]() ![]() ![]() ![]() ![]() What is the usual (main) language spoken in your home?
Interviewer Instructions: What is the highest grade or year of schooling that you completed? (Check one.) ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
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